Medicaid cuts nearly double ED visits by the uninsured
After the Oregon Health Plan, Oregon's Medicaid expansion program, made changes in its benefit package in March 2003, more than 50,000 beneficiaries were disenrolled as a result. Researchers at Oregon Health & Science University set out to determine the impact of this on statewide ED use and analyzed 2,680,954 visits to 26 EDs two years before and after the cutbacks. They found that after the changes, ED visits by the uninsured increased abruptly-from 6,682 per month in 2002 to 9,058 in 2004-and the increase was sustained.
"We expected an increase in ED visits by the uninsured. But we were surprised by the magnitude and by how soon this increase occurred after the cutbacks," says Robert A. Lowe, MD, MPH, the study's lead author and founding director for the Center for Policy and Research in Emergency Medicine at Oregon Health & Science University in Portland.
"We were also shocked to see a near doubling in the number of uninsured ED visits by patients with drug-related, alcohol-related, and other psychiatric conditions," he adds. "The pattern of uninsured visits resulting in hospital admissions was also intriguing."
Uninsured patients were less likely to be admitted than patients in other payer groups, suggesting that uninsured patients often have to rely on the ED for problems that others might get treated by a traditional primary care provider. On the other hand, the odds that an uninsured visit would lead to hospital admission rose by about 50% after the cutbacks, suggesting that a subset of newly uninsured patients were delaying care until they got very sick.
Replication is a danger
The researchers warn that recent federal legislation facilitating similar Medicaid changes in other states may lead to replication of these events elsewhere. "Cutbacks in Medicaid may include cutbacks in the number of enrollees, as well as cutbacks in the scope of benefits for those enrolled," says Dr. Lowe. "Cutbacks in the number of enrollees are likely to result in cost-shifting to hospitals, including EDs and inpatient services."
Cutbacks in behavioral health services, in particular, may force Medicaid enrollees to seek mental health care in a setting that can't provide continuity or cost savings. "As shown by the rise in admissions among the uninsured, the impact on the system is not just financial," he says. "Patients' health is truly put at risk by these policy changes."
What does future hold?
After Oregon's Medicaid expansion was launched in February 1994, the number of emergency department visits declined, as did the rate of hospital charity care. "Although it was not surprising such visits would increase when Medicaid enrollment was reduced, policy-makers no doubt found the specificity of the Oregon Health & Science University research useful," says Jim Edge, assistant director for medical assistance programs for Oregon's Department of Human Services. Oregon is a state of 3.7 million people with an estimated 576,000 uninsured.
Mr. Edge notes that on March 9, 2001, the then-state Medicaid director said the Oregon Health Plan had contributed to a $37 million annual reduction in hospital charity care and an 8% percent drop in emergency department visits.
Oregon's Medicaid expansion, called the Oregon Health Plan, involved expanding coverage to low-income adults who did not qualify for traditional Medicaid. At its peak in July 1995, this part of the Oregon Health Plan, now called OHP-Standard, enrolled approximately 100,000 adults.
In the 2003 budget reductions, the governor and legislature agreed to withdraw state general fund financing from OHP-Standard. "Substituted were so-called provider taxes on large hospitals and Medicaid managed care plans, with both industry groups supporting the tax," says Mr. Edge. OHP-Standard enrollment then was restricted to a monthly average of 24,000 adults during a two-year budget period.
The 2007 Oregon Legislature established an Oregon Health Fund Board, charged with recommending ways Oregon could achieve affordable health care for every Oregonian. Its multiyear recommendation report has four key goals: to expand coverage to Oregon's uninsured populations; to contain the annual increases in health costs; to continuously improve quality, safety, efficiency, and patient satisfaction; and to improve the health of all Oregonians.
The governor, meanwhile, submitted his proposed 2009-2011 budget, which includes $249 million to ensure that all children in Oregon under 19 have access to affordable health care. By the end of the 2009-11 biennium, this program will bring health coverage to an additional 80,000 children in Oregon, achieving coverage for 95% of all kids. The governor's budget provides $962 million to raise enrollments in OHP Standard from 25,000 to more than 100,000 in 2009-11.
OHP-Standard had been closed to new enrollment since mid-2004. "Because enrollment had fallen to a point where several thousand people could be enrolled, the state found a way to make enrollments fair, given that demand far outstrips availability," says Mr. Edge.
So, for five weeks in January and February in 2008, Oregon opened a reservation list to take the names and contact information for anyone who self-identified as low-income and uninsured. More than 91,000 people signed up.
From the reservation list, names were randomly selected by a state computer, with 30,000 OHP-Standard applications mailed to people whose names were randomly drawn during an eight-month period. More than 8,500 people have been enrolled in health care so far, as a result of returning completed applications. "This process is now complete, and OHP-Standard is once again closed to new enrollment," says Mr. Edge.
Contact Dr. Lowe at (503) 494-7134 or [email protected].
After the Oregon Health Plan, Oregon's Medicaid expansion program, made changes in its benefit package in March 2003, more than 50,000 beneficiaries were disenrolled as a result.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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